Gemma McKenzie asks, what's the evidence behind it?
There has been growing interest in the charity 'Count the Kicks' and its campaign to empower women with the knowledge to recognise when a decrease in their baby's movements may indicate potential problems. The charity has enjoyed celebrity support with the likes of Alesha Dixon and Holly Willoughby promoting its work. But what is meant by 'counting the kicks'? And what is the research behind it?
It has long been accepted that fetal movement is a reassuring sign, whereas a reduction in movement is a potential cause for alarm.1 Pregnancies affected by reduced fetal movement (RFM) are at increased risk of an adverse outcome such as fetal growth restriction, premature birth and stillbirth.2 But how much movement is normal? How few kicks are needed to indicate a reduction significant enough to warrant medical intervention? In the past, these questions were frequently asked, and by the mid-1980s various kick charts had been developed. Although there were many different types, they broadly fell into two main schools of thought: the daily fetal movement count and the 'count to ten' or Cardiff method.1
This required the mother to count the kicks for a set period of time. Initially, this was 12 hours, but it was soon moderated to between 30 minutes and 2 hours. One problem with this was to find a time frame long enough to count enough kicks so that a reduction could be noted, whilst also ensuring that the duration of time was short enough for women to be able to comply with it.
This method required the mother to time how long it took to feel 10 kicks. This was to be done at the same time of day, with a view that it is normal to feel 10 kicks within two hours.
Although all pregnant women, regardless of health issues or previous problems, were encouraged to formally count their baby's kicks, it was never an ideal situation. Some of the problems included:
Even with these issues, during the 1980s pregnant women were regularly recommended to formally count their baby's kicks. Then in 1989 a study appeared in The Lancet which put an end to routine formal kick counting.3
This large randomised controlled trial put 68,000 women from the UK, USA, Belgium, Ireland and Sweden, who were between 28 and 32 weeks pregnant, into two groups. The first group was told to formally count the kicks of their baby using the 'Cardiff method.' The second group of women was asked to informally monitor their baby's movements and to report any changes to their midwife. The researchers then analysed the outcome of all of the pregnancies, and in particular those that resulted in stillbirth.
The researchers envisioned that the counting policy would only have an impact on certain types of fetal death. The types they were looking at were the following:
The researchers considered that deaths in category A would be most affected by the counting policy, whereas those in B would only be marginally affected. They also envisioned that deaths caused by C would not be influenced at all by the suggested counting policies.
The researchers concluded that formal fetal movement counting had no advantageous effect on the stillbirth rates. They stated that there was no significant evidence that a policy of routinely recommending formal fetal movement counting leads to a lower risk of antepartum late fetal death. The results suggested that formal counting does not result in a better outcome for the baby, any more than relying on women to informally take note of any changes in their baby's movements.
The study highlighted that introducing a policy that all pregnant women were to formally count their baby's kicks would use considerable extra resources. They estimated that over a year this would lead to '140,000 midwifery hours, 90 million hours of pregnant women's time, 13,000 extra cardiotocographs, and 5,000 more admissions.'3 The researchers also noted that it would take at least 1,250 women with a singleton pregnancy to formally count their baby's movements in order to prevent one unexplained antepartum death.3
Two further points can be taken from this study. An article by Frøen in 20041 highlighted that the death rate during the Grant study was 2.8%, which was much lower than Grant et al's 4% estimate. [The 2013 rate for England and Wales is currently 4.7 stillbirths per 1000 births.4] As the study was so large and it involved different medical staff in various countries, Frøen suggests that the increased vigilance and awareness of reduced fetal movement had a positive effect on the stillbirth rate, highlighting the value of supporting pregnant women to be aware of their baby's movements and to feel confident to contact their midwives should they notice any decrease or change.
A second major point that was raised by both Grant and Frøen was that the response by health care professionals to a woman's concerns of RFM was crucial to whetherthe pregnancy resulted in a stillbirth. Grant stated that: 'In none of the 17 cases [of unexplained stillbirth] where the fetus was alive on reaching formal medical care was emergency delivery attempted after reduced movements had been recognized. This reflected false reassurance from diagnostic testing, especially cardiotocography, and clinical error.'3 Although this statement does reflect the maternity care in 1989 - which it would be hoped has vastly improved since then - it does highlight that an appropriate response from health care professionals is a major factor in the outcome of a woman's concerns of RFM.
Although a woman experiencing RFM should always be able to see a midwife promptly, it can be reassuring to know that the amount a baby moves in the womb and a mother's ability to perceive those movements can be influenced by many factors, such as:
The Royal College of Obstetricians and Gynaecologists provides very detailed information on the management of RFM. Its Green-top Guideline No.5713 outlines all of the relevant research in the area and creates recommendations based on this evidence. This is useful to women who are experiencing RFM, as they can use the guidelines to understand the minimum response they should expect from health care professionals. Some of the notable points include:
Women who are concerned about RFM should not wait until the next day for an assessment of their baby's well-being.
An ultrasound scan should be carried out if:
For women who are between 24 and 28 weeks pregnant, their baby's heart beat should be checked with a Doppler and an ultrasound carried out if the clinician suspects fetal growth restriction.
There are no studies looking at the management of women who present with RFM before 24 weeks of pregnancy. In this case, the guidelines suggest a full antenatal assessment, including the use of a Doppler to listen in to the baby's heartbeat.
The research shows that a pregnant woman is best placed to know when her baby's movements have reduced. As one study recently concluded, 'There is no evidence that formal FMC [fetal movement counting] with their fixed alarm limits are superior to maternal common sense...'2 Formal kick counting has, therefore, been discredited, but a woman's general awareness of the times and frequency of her baby's movements is still a powerful tool in being able to set in motion an appropriate response from health care professionals.
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